Outreach and Peer Education for Drug Users In Cairo s Streets: The Freedom HIV

1. Outreach and Peer Education for Drug Users In Cairo’s Streets: The Freedom HIV/AIDS Program Ehab El Kharrat PhD, MSc Psych,MBBCh

2. Ex-IDUs educating their Peers 22 former drug users work full or part time in the streets of Cairo Reaching out for 1030 street addicts in two years 145 of those reached are now abstinent Reported Needle Sharing dropped from 29% on baseline to 5 % on 6-12 and 12-18months follow-up Unprotected sex dropped from 52% to 25%

3. How Did It Happen? Challenges: 1.HIV/AIDS denial 2.Double stigmatization 3.Fear 4.12-Step resistance 5.The safe sex issue

4. How Did This Happen? Assets: 1.History of doing outreach, but the goal was abstinence only. 2.Strong peer education/involvement, but only as part of the 12-Step and/or TC models 3.Professional and former addicts team 4.FHI bringing in the international expertise and credibility

5. Freedom Identity and History Freedom is a Not for Profit FBO Part of Kasr El Doubarah Presbyterian Church Largest Drug rehabilitation Program in the Arab Region 105 Beds in 4 rehab Centers and one Detox. Over 530 recovered addicts came out of the Freedom Doors A Minnesota Model Abstinence Based Rehab Program

7. Freedom Drugs and HIV/AIDS Program: The Program Context of Peer Education Drug Rehabilitation and Detoxification HIV/AIDS Prevention Outreach among IDUs Drugs and HIV Prevention Training Drug Workers Training A Reclamation Project Follow-up and family activities

8. Freedom Drug Rehabilitation CentreWady El Natroun

9. Outreach To IDUs: Freedom has been reaching out for IDUs from its very beginning: Thousands have been reached since 1989: The strong training heritage helped The sense of a community within the community was an asset and a challenge IDU/Youth Peers:45% of workers and 55% of those reached are below the age of 30

11. Shoubra Outreach Center Peer Education Counseling Meals Psycho-social support Referrals to VCT and other services as required Medical Care Hygiene Services Distribution of IEC materials Distribution of clean clothes

12. Dealing with Special Challenges to Peer Education Professionals doubting the peer education method The program started in 1989 with non- residential drug rehabilitation activities. In 1991 it started its urban residential services in Cairo. In 1996 its farm center started functioning. All the way through we faced the same doubts

13. Dealing with Special Challenges to Peer Education Former Addicts not motivated to work on HIV/AIDS prevention The FHI and MOH training helped orienting and motivating The strong “Freedom” person-centered culture was called upon ( Your abstinence is important but you are more important) The maturation process

14. Dealing with Special Challenges to Peer Education HIV denial: Addiction we see, HIV not yet:5,000-30,000 PLWHA in Egypt Educating the educators: window of opportunity, Russia, Ukraine, Iran, Indonesia, Libya But let us start with the peers passion and interest: moving from your interest to the peers interest Breaking the denial takes time

15. Dealing with Special Challenges to Peer Education Avoiding the risk of relapse: Only use stable former addicts:1- 14 years of abstinence in the streets Training before the work and every 4-6 months more training Pre and post outreach meetings Weekly seminars Move in teams: never left alone with users Two days a week or one day a week of outreach Continuous support to educators

16. Dealing with Special Challenges to Peer Education Can 12-Steppers do outreach for HIV prevention? 12-Step groups were extremely suspicious about the work We called upon the 12th Step tradition of carrying the message We called upon the tradition of admitting powerlessness over hurrying the addict into abstinence

17. Dealing with Special Challenges to Peer Education Did Freedom compromise its strong abstinence history? Colleagues said after 14 years of pioneering abstinence work, Freedom compromised to a harm reduction model Again we need to keep them alive if we want to have anyone abstaining We matured into knowing that abstinence does not come immediately many times We had more people abstaining this way and never written off the abstinence goal

18. Dealing with Special Challenges to Peer Education Perceived Challenges from the culture Actual reality neighbors did not mind Not a single incident from the streets Landlord did not mind

19. Dealing with Special Challenges to Peer Education HIV/AIDS Stigma Authorities in dilemma An official stamped “letter” of “conducting research” not of doing outreach/peer education, no IDs delivered til now

20. Changing a Subculture What did addicts in Cairo believe about HIV/AIDS high risk behavior? Buying clean syringes before buying the “stuff” is a jinx ! Hepatitis C is a problem but HIV is not

21. Dealing with Special Challenges to Peer Education What did recovering addicts believed about the non abstaining addict? Will never trust a non-addict Do not like themselves enough to protect themselves Need a relationship more than the information Education does not come except through a relationship Mostly these beliefs were proven true

22. Working with Stigma Government balance needed Female addicts-a double stigma True stories of educators with law enforcement

23. Challenges of Follow up Why would I give you my correct contacts? Following up a population on the run Changing residence, family issues and selling your phone line

24. Unsafe Sex how and when can it Change? What are the sexual beliefs of street addicts? What are the sexual beliefs of recovering addicts? The meanings of sex: pleasure, conquest, shame versus expression of love, respect and commitment Using addicts are mostly not expected to change their life views to reach sexual abstinence or faithfulness without abstaining from drugs, but progress is possible

25. The condom issue The Condom Issue Focusing on not sharing needles more Effort to understand the issues

26. Change In Unprotected Sex Behaviour

27. Change In Injection Behaviour

28. Peer education to addicts why does it work? Trust Empathy Knowing the tricks Knowing the language A shared stigma A shared hope Communicating self worth

29. Can a Peer educator be a researcher? The challenge of documenting Passion and science Doing more than what is needed Trusting the institutions Age groups and social classes

30. Lessons Learned on Working with Marginalized Groups Start with their interest e.g. from addiction to HIV Find assets within the sub-culture e.g. carrying the message Find assets within the culture e.g. tolerance Plan for contingencies but expect possibilities e.g. neighbors not resenting They may better know the real problems e.g. the jinx belief